I’ve spent the last 15 years in the tech startup community including several early stage ventures with successful exits in the healthcare space. I'm also a Top Writer on Quora (2012 and 2013) for several healthcare specific topics. I'm likely to include film references and quotes as in "All of life's riddles are answered in the movies." Twitter handle is: @danmunro

The author is a Forbes contributor. The opinions expressed are those of the writer.

An ePatient's Reply To 'A Doctor's Declaration Of Independence'

For those who missed it, Dr. Daniel F. Craviotto Jr. issued “A Declaration of Independence” in yesterday’s Wall Street Journal (Opinion ‒ here). Based strictly on the number of comments (766 at last count) and tweets (1,935 and rising), it’s safe to say it struck a resonant chord in the healthcare community. It did with me too.

His opening sentence is the framing he chose to launch into a 700+ word teardown of what ails the system overall and more generally a provider’s ability to practice medicine effectively (in his own case as an Orthopedic Surgeon).

“In my 23 years as a practicing physician, I’ve learned that the only thing that matters is the doctor-patient relationship.” Dr. Daniel F. Craviotto, Jr. ‒ Orthopedic Surgeon and fellow of the American Academy of Orthopedic Surgeons

A brief summary of the frustrations he cited were these:

Mandated use of an Electronic Health Record (EHR) by the Centers for Medicare and Medicaid Services (CMS)

Lower Medicare reimbursement rates in the future for failure to use an EHR

Declining Medicare reimbursement rates more generally

Unnecessary “interference” with the practice of medicine

Letting “nearly everyone trespass on the practice of medicine”

He used the word “tired” no less than 4 times in one sentence

Channeling the now famous quote from the 1976 film Network ‒ he ended his 3rd paragraph with the provocative battle cry:

“When do we stand up and say we are not going to take it any more?”

I encourage everyone to read it ‒ but I don’t think his criticisms are remotely patient‒centered or patient-engaging. More broadly, I don’t think it’s representative of the provider community either. Here’s why.

Of all the times to highlight any of the perceived injustices around provider billing or compensation ‒ this probably isn’t it. Here are some of the stats we’re all trying to grapple with ‒ nationally:

National Healthcare Expenditure is now over $3.5 trillion ‒ per year (about 18% of GDP ‒ here)

Of the 25 Specialties tracked by Medscape (annual survey of 24,000+ physicians here) ‒ Orthopedics had the highest average annual compensation ‒ $413,000

Taking the lowest compensation (HIV or Family Medicine at $174,000) and the highest (Orthopedics at $413,000) the median across all 25 specialties is about $294,000 ‒ per year

That’s just a small sampling of the provider world that we have a glimpse into (and doesn’t include medical errors or mis/over diagnosis). Now let’s take a look at the patients.

According to The Commonwealth Fund (here) there were 84 million non‒elderly (under 65) Americans that were either uninsured ‒ or underinsured during 2012 (that’s almost 1/3 of the non-elderly population)

46% of New Yorkers (pop 20 million) are either poor ‒ or nearly poor (NYT, Dec ‒ 2013 here) (correction: the 46% applies to New York City ‒ population 8.3M ‒ not the state)

There are nearly 100 million Americans that are “either in poverty – or in the fretful zone just above it” (NYT, Nov ‒ 2011 here)

The Milliman Medical Index (which tracks PPO coverage for a family of 4) is now over $22,000 per year (here)

Contrary to some popular beliefs, the Medscape Survey suggests a much more even split around the exact issue of being fairly compensated .

In regard to feeling fairly compensated or not, it was a 50‒50 split among all physicians who responded to the survey this year. Primary care physicians were only slightly more negative, with 52% saying they did not feel fairly compensated while 48% did. Considering the ongoing income disparities between primary care physicians and specialists [see chart], their having the same perception is somewhat interesting. There has been very little change in the responses to this question over the past 3 years.

Another interesting artifact of the Medscape survey was this one:

In this year’s Medscape report, the perception of being fairly compensated does not correlate to actual compensation for many physicians. Orthopedists were the most highly paid physicians, but they fell below the middle of this list, with only 45% believing that they are fairly compensated.

Relative to the mandated use of an EHR ‒ most of which are poorly designed for any clinical purpose ‒ I totally agree. From a patient’s perspective ‒ it’s even worse. When we do ask for “copies” of our record or lab results ‒ it often results in a pitched battle with providers and hospitals (with mandatory HIPAA “authorizations”) which can also mean multiple phone requests, emails and (yes) faxes. When we offer an email address for any replies or communication ‒ it’s not uncommon to see a quizzical look.

In fact, it’s an easy argument to make that EHR systems generally have all been designed around scheduling and billing ‒ not clinical documentation (let alone patient engagement). That’s an important and fair criticism ‒ but it also heavily favors providers for the express purpose of billing and scheduling (ie: the revenue engines of every practice and provider setting).

But none of this is unique to EHR’s. The system overall has been optimized around revenue and profits ‒ not safety and quality. The EHR systems we have (all 400+) reflect that ‒ and the competitive nature of the whole EHR industry makes any interoperability next to impossible ‒ often within the same brand. I wrote extensively about the lack of healthcare interoperability last month (here, here, here, here and here).

I don’t blame the healthcare industry for the status quo anymore than I would blame the engine of a car that only gets 3 miles-per-gallon. Without knowing the car, we can reasonably assume that the engine has been optimized for horsepower ‒ not MPG. I don’t blame the engine for that ‒ but if we need more MPG (and I think that’s without dispute), we need to radically re-engineer the engine.

That’s effectively what Obamacare (and all the bureaucracy) is attempting to do. Granted it’s the very first step out of our healthcare wilderness, but it is a first step and it does extend health coverage to millions that have been without. I know some of them will absolutely need the services of a great Orthopedic Surgeon.

Post Your Comment

Post Your Reply

Forbes writers have the ability to call out member comments they find particularly interesting. Called-out comments are highlighted across the Forbes network. You'll be notified if your comment is called out.

The problem with your analysis is the same as the problem of ALL socialist-style analyses: 1) people will naturally act in their own interests, not that of the herd, and 2) people have the free will to respond when they are unhappy.

The author – and I – will, and have, responded to an onerous workplace. I retired at 58, when I would have liked to practice until my ‘seventies. Others will do the same. All the moralizing in the world wont change that, nor will all the statistics about healthcare costs.

If you want to solve the problem, attack the real cause of the high costs of medicine: the government itself. Any time a player with infinitely-deep pockets gets in a game, the costs go up. It ain’t rocket-surgery.

Government isn’t the problem here – although it’s a popular scapegoat. Medicare is pretty good – and efficient (relative to private insurance).

We don’t need single payer – and it wouldn’t fit us culturally – but the engine we have is broken when it forces 84 million people (1/3 of the non-elderly population) into being uninsured or underinsured.

I don’t want to get into a “he-said, she-said” here, but I beg to differ. Yes, there is no question that the system doesn’t work – as a doctor WHO WAS IN THE TRENCHES FOR THIRTY YEARS, I watched it go from working to not-working, so I’m not just sitting on the sidelines taking potshots.

And here’s how it happened: the government decided in the ‘sixties to pay for SOME things. Painfully oblivious to the fact that the government has no money, and everything it buys is paid for with money taken from people who earned it, everybody thought this was a good idea. By flooding the market with dollars, entrepreneurs did what they always do – they figured out how to get some of that money. This drove the cost up.

As costs went up, government said, “You people are getting gouged; what you need is MORE government to protect you.” Now MORE involvement and HIGHER costs. Rinse and repeat.

The waste from “free care” is staggering. As a radiologist, I would typically read for an hour, then take a ten-minute break and a short walk to stand outside the ER doors for a little fresh air before going back in. I cannot tell you the times that I observed an ambulance careen into the parking lot, lights flashing, back up to the ER doors to disgorge an overweight twenty-something girl strapped to the gurney – sitting erect – texting.

We had noticed the enormous costs we were encountering for our after-hours ultrasound call-ins. We discovered that our pregnant Medicaid patients had found that they could come in at three in the morning – (why not; days and nights have no meaning when you are not employed), claim vaginal bleeding and that automatically bought them an ultrasound. Then they could learn the sex of their babies. No cost to them, but our cost? About $1200, all told. Medicaid paid about $40 of that. Think they would have used scarce, expensive resources so cavalierly if they had to pay the bill? You see this kind of behavior in no other business. I stopped the ultrasound technicians from sexing the babies after hours and the problem ended.

Now tell me again that the government is not the problem. Walk a mile in the shoes of people who actually work in this system before you diagnose its problems and prescribe its cure.

I read this post and a few others on your website. You have EZ access to a huge range of statistics, which is a resource most of us don’t have. You can make a much bigger contribution to this issue if you climbed out of the weeds and took a look at the puzzle from 10,000 feet. The reason a thousand articles a day on the subject don’t make any headway is they don’t have the ability, and haven’t put in the effort, to gather the puzzle pieces together so the colors form logical pictures. Here’s just a sample approach, for example.

Dr. Creaviotto complains about the EHR problem. You state, “The EHR systems we have (all 400+) reflect that ‒ and the competitive nature of the whole EHR industry makes any interoperability next to impossible ‒ often within the same brand.” So, the REAL STORY is: how did the Obama administration ever expect the EHR industry to solve this problem in the first place?

I’ve been in the middle of this issue since 1992. The most “plausible” explanation I’ve heard so far is a wild one. In the Dem-Rep battle, the public has been brainwashed to salute any flag that has “capitalism” or “free market” on it. So, the Obama people, believing they could never even begin to FORCE the construction of a workable system, decided to let the Republicans VERY OPENLY WIN on this issue. The doors of our so called “free market” were opened wide to the EHR industry, with $24B funding no less, and the result allowed to fail in a MASSIVE SNAFU! With major egg on their face, the Republican’s would fold, and some single system, like the VA system, would be rammed into place.

Of course, seeing how the Democrats botched the much smaller ACA registration system, and knowing how badly the VA is managed, that approach would also fail. So, what’s the real story there? Here’s where a powerhouse like Forbes can really help. 1. Pull together all the statistics you need to get a true picture of the problem; 2. Convene a broad conference of leading IT people and put them on the carpet. Give them 6 months to come forward with a JOINT industry solution; 3. Anticipating they might fail, find another “army” that has the ability to create and implement a plan B (French? British? Germans? Canadians? They all have already done this.); 4. With solution in hand, force congress to move on the proposed solution, by confronting them with the fact that their skirmishing had suppressed an approach so simple any high school kid could have figured it out.

It’s actually much bigger than this – but I didn’t go into the real problem – campaign finance reform. Real leadership isn’t on the ballot – Dems or Repubs. Lawrence Lessig’s view is the right one here. Campaign Finance reform isn’t the biggest problem facing our country – but it’s the first.

Dan – You stepped into a culture war with this commentary. Indeed, a functional Congress might be able to lead us out of our domestic health care mess. The rest of us have responsibility, though. Pogo’s observation about the state of the physical environment almost 50 years ago is applicable, “We have met the enemy …and he is us.” I suggest that government support for private IT systems is misguided and the nature of US politics has made our situation worse. May I suggest the term “Medicapitalization” to describe our incoherent mashup of social spending and misguided financial incentives? However, it is simpler to parse the essence of Dr. Craviotto’s lament which seems to be a desire to make a very good living from public investments in his education, in medical technology and for patient services without accountability to the public’s representative for the value (to the public not individual patients) of these investments. He certainly has the right to complain, retire or just serve private patients, but I would hope that he would instead serve a constructive role in helping to deliver the benefits of medical knowledge and technology to all our citizens, not just the wealthy, the well insured and the famous.

I couldn’t agree with you more on the Medicapitalization. Why we need (and pay to support) 400+ ISV’s to build, install, manage and maintain “EHR” software is clearly misguided. Much of the software is painful to buy and install – let alone use – largely because it’s been built around scheduling and billing – clinical efficacy is/was largely an afterthought.

I’m becomming convinced that Lawrence Lessig is right. Campaign Finance Reform isn’t the biggest problem facing the country – but it’s the first. The corrosive effect of campaign financing has permeated pretty much every aspect of D.C. You might like Lessig’s 18 min TED talk (from last year – here: http://hc4.us/LLessigTED )

In the end – the healthcare industry we have has been built largely around revenue and profits – not safety and quality. I’m not blaming anyone – but I do think we need to move to safety and quality as the foundation forward. Getting there will clearly take quite a while – especially at this pace. Rick Scott (Governor of FL) has the best quote: “How many businesses do you know that want to cut their revenue in half? That’s why the healthcare system won’t reform the healthcare system.”

1. Check when medical costs began to skyrocket (Hint: See July 30,1965)

2. “I have often wondered at the smugness with which people assert their right to enslave me, to control my work, to force my will, to violate my conscience, to stifle my mind — yet what is it they expect to depend on when they lie on an operating table under my hands? Their moral code has taught them to believe that it is safe to rely on the virtue of the victims. Well, that is the virtue I have withdrawn. Let them discover the kind of doctors their system will now produce. Let them discover, in their operating rooms and hospital wards, that it is not safe to place their lives in the hands of a man whose life they have throttled. It is not safe, if he is the sort of man who resents it — and still less safe, if he is the sort who doesn’t.” –Dr. Thomas Hendricks, “Atlas Shrugged,” by Ayn Rand